In our rush to offer “McMedicine,” do we even know what patients really want?

Primary care covers a wide range of acute and non-acute issues, including preventive care and chronic disease management. And yet, same-day or next-day access features prominently in performance reports about primary care. It’s a key patient survey metric highlighted by the Commonwealth Fund Study, where it’s used to compare our health system’s performance with that of other countries. It’s also a key feature of the Ontario government’s recently passed Patients First legislation.

But access to primary care is a multi-dimensional concept. It includes considerations like geography, urgency, and continuity. How far must a patient travel to access care? Would they prefer to delay a non-urgent appointment in order to see their own doctor? I recently collaborated on an Ontario study of patients’ access to their primary care practice that looked not just at the wait time for an appointment, but 10 other aspects of access, including ease of getting to the practice, availability of after-hours services, and access to allied health professionals like nurses and social workers.

The unsurprising finding was that, similar to the Commonwealth Fund Study’s results and the Ontario Ministry of Health and Long-term Care’s reports, most patients (68 percent) waited more than a day for their appointment.

What did surprise us, though, was that most patients (96 percent) said it was easy to get their appointment, and most (87 percent) said they got their appointment for when they wanted it. Patients felt quite positive about their access overall, with 74 percent responding favourably across all 11 dimensions, a finding that challenges the common narrative that access to primary care in Ontario is poor.

In the Health Care Experiences Survey that the MOHLTC uses, we see a similar pattern: Although the same day/next day access is low (43 percent), patient-reported timeliness of access (the data for which is available upon request from the ministry) is much higher at 70 percent. There’s obviously room for improvement in timeliness here, but the situation seems far less dire than what the results for same day/next day access alone would suggest.

So, big deal, one might say. What’s the problem with featuring same day/next day appointments as a prominent quality indicator even if it may not be perfect? Well, there are many problems with focusing on this measure.

1. We promote convenience over continuity

As I wrote previously on Healthy Debate, we are already seeing a concerning shift in health care toward what some have termed “McMedicine.” Patients are offered virtual physician consultations while they’re at the pharmacy. There’s a walk-in clinic smack dab in the middle of the local Walmart. Cellphone apps promise assessments and diagnoses via text message.

Developing policy that explicitly prioritizes same day/next day access, despite the lack of evidence that this improves outcomes, further ingrains convenience medicine into our culture. This comes at the cost of a quality indicator that is much more important: Relational continuity, which means seeing the same provider for most of one’s primary care. Relational continuity is associated with important outcomes both for patients and the health system (costs, integration, communication), and it gets disrupted when policies prioritize same day/next day. Recognizing the importance of continuity, Health Quality Ontario, which reports annually on primary care performance in the province, included it as a quality indicator for the first time in 2017.

2. We perpetuate myths about emergency department use

An idea persists in Canadian health care that emergency department (ED) backlogs are due to low-urgency visits that could be seen in primary care if only those patients could get same-day access to their family doctor.

Not only is this unfounded, it risks preventing us from finding solutions to the actual issues underlying ED overcrowding: Overflowing inpatient wards, too few long-term care beds, an inadequate supply of home care services, the lack of community-based after-hours diagnostic services like imaging and bloodwork, and the unique setting of rural medicine, where family doctors are often responsible for providing ED services.

3. We risk overwhelming an already strained primary care sector

Primary care does not operate within a vacuum. Access is influenced by many external factors over which primary care providers often have little or no control. For example, lengthy wait times can drive repeated contact with primary care by patients who should have long ago received specialty care, or by patients whose medical issues—and in turn, treatment plans—remain unclear until they can finally get that biopsy or MRI. As family doctors, we’ve all seen patients who wait up to 18 months for their knee surgery and require our help to manage their pain in the meantime. We’ve all seen complex mental health patients who face excessive waits for psychiatric care—even after a hospitalization or a suicide attempt—and similarly require our help in the meantime.

So what can we do to better measure access to primary care?

First of all, we need policymakers to focus on gathering data that capture the complexity of access and prioritize timeliness. In our study, patients were asked questions like: “Can you see other doctors in this practice if your doctor is not available?” “Are the opening hours too restrictive?” and “Were you able to arrange an appointment for as soon as you wanted to?” When analyzing data, we need to be mindful of the ways in which patients may have interpreted the questions. For example, in the Commonwealth Fund Study and the ministry’s survey, the wording of the same day/next day questions might actually be capturing both urgent and non-urgent visits.*

Second, we should collect data from multiple sources. Most access studies (including ours) have limitations such as low sample sizes, sampling bias, and recall bias. Even one of the best resourced studies out there, the Commonwealth Fund Study, has a response rate of only 21 percent, and likely misses vulnerable or unique populations such as low-income patients, Indigenous populations, rural patients, and new immigrants and refugees. To more accurately gauge access, we need to collect data at the patient level, the physician level, and the practice level. Family physicians should receive funding and other supportive infrastructure to do this in as unobtrusive a manner as possible.

Third, we need to approach access as a philosophy rather than taking a prescriptive, one-size-fits-all approach. If our patient calls needing a same-day appointment, we should do what we can to accommodate them, but what that looks like will vary from setting to setting, with consideration for issues like rural family doctors’ commitments to servicing their EDs and hospitals. Practices can look to “open access” or “carve-out” scheduling, offer telephone follow-ups, emails and team-based approaches, all of which have been demonstrated to reduce wait times for primary care appointments.

And finally, to meaningfully address access to primary care, we need to look at the “whole system.” Innovative solutions to wait-lists, referral systems, and communications with patients and specialists, would help alleviate some of the pressures that have direct, negative effects on access to primary care.

Focusing on the “same day/next day” metric not only risks missing opportunities to truly improve access, but also risks undermining other important dimensions of quality, causing real harm to our patients and to our health care system as a whole.

*Commonwealth Fund Study: “The last time you were sick or needed medical attention…”

Ontario Ministry of Health and Long-term Care’s Health Care Experiences Survey: “The last time you were sick or concerned that you had a health problem…”

Enter the debate: reply to an existing comment

20 comments

James PookayMarch 28th, 2018 at 7:50 pm

As a walk-in clinic physician, I’ve never had a patient tell me that they can access their family doctor on same day or next day. Many patients tell me they tried calling the office earlier in the day and were offered an appointment in six weeks’ time.

Obviously, my work environment creates some selection bias, but I see patients constantly from the same usual suspects’ rosters over and over. Sometimes I see a half dozen patients in a row from the same physician’s roster.

It seems as though many of my colleagues seem to be q 3 monthly refill machines that are inaccessible for anything else.

I don’t believe the 96% satisfaction with ability to get an appointment for a second.

Thanks for your comment, James. It was a patient survey so all the data comes directly from patient self-report. The Ministry of Health’s data (also patient self-report) on timeliness is 70%, which is lower than our sample’s findings (87%), but still better than what the same day/next day metric alone would suggest. There’s previous literature finding that many patients visit walk-in clinics without trying to call their family doctor first, and other literature finding that patients tend to visit walk-in clinics for reasons related to convenience (e.g., geography, time). I agree with you that there are truly problems with access in some areas and some practices — like you, I saw this in my own experiences servicing a walk-in clinic for 6 years. If we replace same day/next day with “timeliness”, we should be able to capture both urgent and non-urgent visits, and if we broaden our approach to evaluating access, we will avoid unintended negative consequences that can result from focusing too heavily on a single metric.

Hi James,
As you said, your practice might include some selection bias…so I will politely counter that perspective: while there are certainly some physicians that, over time, have likely accumulated large rosters that cannot offer timely appointments, or physicians with blended practice that aren’t able to offer as many office hours, for the most part I find the actual access vs. patient’s preferred access to be a large influencer in the outcome of where they end up being seen. I’ve had the opportunity as a Locum over the past few years to work at least 6 different practices/practice models (FHT/FHO/FHG/FFS/AFP) quite regularly, as well as the Walmart walk-in (literally) and rural EDs. Most if not all of these practices had availability for patients within 2-3 days, and mostly same day. Clinics were often offered in the evening, and almost all had the ability to be seen by another doc or NP within the clinic. The number of patients who still chose to attend the ED or another WIC due to their work schedule or convenience for location was still quite high. In fact, I’ve had my own evening clinic running with open spots and seen my patient’s name suddenly show up on my colleague’s appointment list running a concurrent after-hour walk-in clinic! He just hadn’t even called to check if I was available to see him – I promise he wasn’t trying to avoid seeing me specifically :). In northern & more rural areas, it’s common practice for the patients to go to the ER when they know their GP is covering rather than the office for non-acute issues, for convenience. In the GTA walk-in, it wasn’t uncommon for people to tell me their doctor could see them that day, “but I work at Rutherford Rd and he’s all the way at Jane & Steeles”, or another patient who’d already seen her GP that same day but didn’t want to wait for the urine C&S he’d done to come back, so hoped I’d give her antibiotics instead, despite a negative dip.

Those are obviously also cherry-picked scenarios, not reflective necessarily of all or most patient experiences, but I’m definitely echoing this author’s commentary from my practice point of view as well; emphasis on a target or metric should be validated by more than just the idea that it appeals to our general sense of what the public demand is. It needs a further look, and above all more public education! Honestly I often don’t blame patients for their actions half of the time; the system is confusing and the lack of understanding on how our primary care systems actually work doesn’t allow them to recognize the ways in which they often misuse it and/or fail to take advantage of it even when we try to accommodate their needs. Appreciate the article, Kamila, and appreciate the perspective James, just adding another one to the abyss of online commentary…hoping we can actually contribute to meaningful policy change, as well.

Thanks for the perspective Emily and for the very well-written article Kamila. I work in a small town ER and have the privilege of also locuming frequently to cover many of the family practices in town, so I know who has after hours access, who will always squeeze a sick kid into their day etc. Most practices are very good at providing same day/next day access for truly urgent issues, although patients are not always aware of this. (And every physician in town can tell you who the ‘problem’ practices are for long wait times for appointments – yes there are always a few!) I can call patients out when they obviously haven’t called their GP’s office first … My favourite question for patients I see in the ER with ‘X pain for X weeks/months’ is “so what does your family doctor think about this?” … it elicits some sheepish looks! But ultimately it is important to take each opportunity to educate patients and help them try to navigate the system, for their own benefit as well as for the sustainability of the system.

Excellent article Kamila, great to see you taking on such a complex and important topic. I concur with your analysis that we need to think and measure more creatively and responsively. Keep up the good work!

Excellent article.
We are experiencing the same effect in Quebec with the establishment of “superclinics.”
I agree – McMedicine does not mean “supercare.”
As you correctly point out – the importance of “relational continuity” is often ignored in favour of fast-food results.

Kamila…. brilliant.
This article need to be shared widely with a policy focus on change, not just an “opinion piece”.
Multiple data sources are possible: EMR, PREMs, administrative data, even qualitative data in all its impurity.
Thank you thank you thank you!
D

Thanks for touching on the role of qualitative data, Darren! This is so important in the complex, adaptive world of healthcare, where linear, quantitative data can mask the subtle nuances that are critical for understanding what’s really happening, and what it means to provide quality care. A qualitative piece would be a useful complement to this study, and is certainly percolating in my mind!

I totally understand. At one point I tried to introduce the concept of an eVisit to the doctor for rostered patients to the ministry of health but did not go any where. Like you say a large percentage of doctor visits are not urgent in nature. In many areas patients go to emergency at the hospital for these type of visits.

Thanks a lot for your article Kamila. Indeed the metrics for accessibility to primary care is complex. What interests me though is how we might describe timeliness. Who defines it? The patient? Do we know if they will define it beyond same day/next day access?

Thanks, Yabuko. Important question. I think patients should drive the definition of timeliness — something along the lines of the *acceptability* to the patient of the wait time for the appointment (or other form of access) they were offered. Qualitative patient data, as Darren Larsen has highlighted, could help us with these definitions. HQO and TRANSFORMATION PHC have been working on this:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5344364http://www.transformationphc.ca

The data from our study and the MOHLTC survey suggests patients do define acceptability beyond same day/next day, with higher scores on acceptability measures. There’s a tricky balance here between acceptability of the wait time and matters of convenience. Sometimes, for example, I can offer my patient that same-day appointment that they’re requesting, but might not be able to accommodate the particular time they want. Sometimes, our patients can meet us half-way on this — and this is the ideal scenario, as it preserves relational continuity. Other times, we can get around these issues through infrastructure support for things like team-based care, telephone appointments, and emails. We need funding and other resources to make this happen. If you’re interested, I wrote some more about access and what it might mean to patients here: http://healthydebate.ca/opinions/what-does-access-to-primary-care-really-mean

Thanks for reading, Patti, and I’m sorry you’re facing difficulties accessing your primary care practice. There are definitely regions and practices where access is challenging. Have you spoken with your family doctor about the difficulties you’ve encountered? Feedback from patients helps us improve, and hopefully your practice can work with you to find solutions.

It’s pretty simple. When a patient seeks care because of symptoms or an injury, provide same-day access to that patient’s regular doctor – not a walk-in-clinic within standard practice – because continuity is preferable to fragmentation. When a patient prefers to book an appointment at a specific time, accommodate the patient. When a patient doesn’t care, book the appointment at an available time in the schedule. All of these common-sense, patient-centered options are easily achievable in most communities. Canada has about 1 family physician for every 900 to 1000 people. High-performing American health sub-systems provide this standard of convenience with ratios up to 1800:1. In a team-based environment patients don’t always have to see the doctor.

As a patient I would be thrilled never to have to see my doctor in person: use the technology, including phone, email, skype, remote data collection, monitoring, etc. Dr. Premji makes valid points about satisfaction and that access alone is not a proxy for quality. However, that Canadians may express satisfaction with access doesn’t mean that it’s good; it just means that we have adjusted our expectations downward, mistaking an organizational failure for a problem of supply. The Commonwealth Fund study isn’t perfect, but it’s good enough to take seriously, and Canada is always at the bottom on access. There are completely unnecessary barriers to convenient, patient-centered service, some resulting from perverse financial incentives (my doctor won’t get paid if he sees me on skype), and some from a widespread failure to adopt proven access-enhancement measures. Rather than suggest that it’s not truly broken so there’s no urgency to fix it, I would reverse the onus: why isn’t every primary care practice organized to deliver convenient care?

We know the answer. Primary care medicine, with some admirable exceptions, is still a cottage industry with an obsolete payment model and little real accountability for performance on any measure. Full-service family physicians are increasingly rare. Walk-in clinics, widely decried within medicine, are a perfectly reasonable response to the failure of primary care to provide patients care when they need it. They could be put out of business if comprehensive primary care clinics took the access problem seriously. It’s quite possible that the patients who say they are satisfied with the access provided by their regular source of care use the walk-ins as a workaround.

Kamila, this is a thoughtful and valuable contribution to the discussion. However, your reference for the premise that 10% of primary care visits are urgent is old and from a special clinic. It is not generalisable, and needs to be researched further. And if the proportion of urgent visits really is 10% in current clinics, that does not measure the unmet need or “wants”. If Family Physicians were more easily available, the proportion of urgent visits might be 20%. If we did not fill clinics with “routine” repeat visits, or useless “preventive care” then we would be more readily available for urgent problems. Urgent availability is important because of anxiety. For example, when a parent is worried about their child being ill, they can wait until standard hours if they know that if things get worse, they can be seen quickly. Thus the perception of availability is important and may not be captured by studying, for example, the answers to questionnaires given by patients actually attending a continuity of care clinic. We need to understand the concerns and the sequence of events for those who did not attend, and went to walk-in clinics instead.

There is also a proportion of the population who do not “plan” their health care: often who are in marginal jobs, so must go when they can. Many of these may be immigrants, whose perception of health care is different from the Canadian standard. Some come from places where appointments do not occur: you just go to the clinic and queue. We must also recognize that some people have disorganized lives, have difficulty planning ahead, and want immediate resolution of their concerns. How well do we serve these people? And how well does our research capture their perceptions and needs, since they are likely not to complete questionnaires, or stick around for interviews?

The comparison between your article and responses from the many like James Pookay, and the businessmen who setup walk-in clinics show that there is no meeting of minds, just talking past one another. These are two different realities. Understanding “the other” is critical, as Patti Groome points out. There is need for much more careful research in this field before we can be confident that we fully understand the situation.

The 10% stat is unfortunately the most up-to-date stat I can find. It aligns with the ~8.5% of patients in our sample who reported their visit as being urgent and probably resonates as a reasonable estimate for many family doctors, but as you’ve pointed out, due to other confounding or biasing factors, it’s hard to know just how accurate it is. That said, I included it because I suspect the ratio of urgent:non-urgent primary care needs is disproportionate to the amount of focus we currently give to same day/next day, and I worry this will eventually result in negative impacts as seen with some of the U.K.’s access-oriented reforms. As you’ve said, I don’t think we fully understand access just yet, nor do we adequately capture the experiences of “the other” in studies like ours. This study was an attempt to address some of the gaps by taking a more comprehensive approach to understanding patients’ experiences of access.

I agree with you that we should absolutely be aiming to be available for patients who request a same-day visit for their concern — it isn’t the intent of the commentary to argue otherwise and I apologize if that wasn’t so clear. Rather, the intent is to move the metrics toward data focusing on patient-reported timeliness and patient-reported acceptability of their primary care appointments, which would hopefully be able to capture urgency. Your idea of looking at patient perception of availability is important. Should the same day/next day access metric persist, it may be worthwhile to re-examine the question stems generating this metric, which I think currently risk capturing a broader range of urgencies than intended.

No easy answers. Ultimately, I think the third solution discussed in the commentary (access as a philosophy) is the most patient-centred approach, with other strategies like innovative scheduling, after-hours care, alternate modes of contact, and mechanisms for patient feedback supporting us in this aim.

Thanks Dr. Premji for highlighting the often undervalued concept of continuity of care that patients benefit from when having a primary care provider. Team based care is a great concept to allow utility of health care professionals skills and knowledge but it can not be at the cost if causes fragmented care. As a NP working in primary care I often feel confused what my role is suppose to be in Ontario. My scope of practice and training allow me to provide primary care. So am I a provider giving relational continuity care to patients? Or allied health..thus no ownership to being attached to patients long term. This non attached models to NPs leaves patients vulnerable to having no input to keeping a NP as their provider. For ex. organizations restructure or/and physicians retire and hence their roster of patients are taken by a new rostering MD.

Also with insurance companies like sunlife soon to be offering virtual primary care with conveniences (getmaple,akira); how will patients view primary care? convenience valued over continuity; fast access despite fragmented care?
would love to see you post this article on twitter? @gerritsenbeth
sincerely appreciate your work
Beth

Access to Health and Care needs to include the ‘allied health professionals’ and be considered as primary to primary care as physicians. Robust attention to supporting self-management and health promotion will affect wait times for people needing disease management supports. Please direct me to this debate in Ontario.
Thanks for your intriguing article.

This document is provided under the terms of a CreativeCommons Attribution Non-commercial Share Alike license. The terms of the license are available at: http://creativecommons.org/licenses/by-nc-sa/3.0/. Attributions are to be made to HealthyDebate.ca, a project under the direction of Dr. Andreas Laupacis, at the Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael’s Hospital.